First Aid 2 CS Mini cases

question

What are the key history questions you need to ask for HEADACHE?
answer

Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep?); presence of associated neurologic symptoms (paresthesias, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness); nausea/vomiting; jaw claudication; recent trauma, dental surgery, sinusitis symptoms; exacerbating (stress, fatigue, menses, exercise, certain foods) and alleviating factors (rest, medications); past history of headache; family history of migraines
question

What are the key history questions you need to ask for HEADACHE?
answer

Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep?); presence of associated neurologic symptoms (paresthesias, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness); nausea/vomiting; jaw claudication; recent trauma, dental surgery, sinusitis symptoms; exacerbating (stress, fatigue, menses, exercise, certain foods) and alleviating factors (rest, medications); past history of headache; family history of migraines
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What are the key physical exam maneuvers you need to do for HEADACHE?
answer

Vital signs; inspection and palpation of entire head; ENT inspection; complete neurologic exam, including funduscopic exam.
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Give the Differential diagnosis for the following presentation: 21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees fl ashes of light in her right visual fi eld and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.
answer

Migraine (complicated) Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis Partial seizure Intracranial neoplasm
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Give the workup for the following presentation: 21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees fl ashes of light in her right visual fi eld and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.
answer

CBC ESR CT—head MRI—brain LP
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Give the Differential diagnosis for the following presentation: 26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minute:
answer

Cluster headache Migraine Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm
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Give the workup for the following presentation: 26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minute:
answer

CBC ESR CT—head MRI—brain LP
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Give the Differential diagnosis for the following presentation: 65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing:
answer

Temporal arteritis (giant cell arteritis) Migraine Cluster headache Tension headache Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm
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Give the workup for the following presentation: 65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing:
answer

CBC ESR CRP Temporal artery biopsy Doppler U/S—carotid MRI—brain
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Give the DiffDx for the following presentation: 57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.
answer

Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm
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Give the W/u for the following presentation: 57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.
answer

CBC ESR MRI—brain
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Key Historical questions for confusion/memory loss
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Must include history from family members/caregivers. Detailed time course of cognitive defi cits (acute vs. chronic/gradual onset), associated symptoms (constitutional, incontinence, ataxia, hypothyroid symptoms, depression); screen for delirium (waxing/waning level of alertness); falls, medications (and recent medication changes); history of stroke or other atherosclerotic vascular disease, syphilis, HIV risk factors, alcohol use, or vitamin B12 defi ciency; family history of Alzheimer’s disease
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Key Physical exam man for confusion/ memory loss:
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Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities
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Give Diffdx for the presentation: 81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).
answer

Vascular (“multi-infarct”) dementia Alzheimer’s disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial tumor Depression B12 defi ciency Neurosyphilis Hypothyroidism
question

What are the key physical exam maneuvers you need to do for HEADACHE?
answer

Vital signs; inspection and palpation of entire head; ENT inspection; complete neurologic exam, including funduscopic exam.
question

Give the w/u for the presentation: 81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).
answer

CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis (rare)
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Give the diffdx for the presentation: 84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with diffi culty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
answer

Alzheimer’s disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 defi ciency Neurosyphilis
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Give the w/u for the presentation: 84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with diffi culty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
answer

CBC VDRL/RPR Serum B12 TSH MRI—brain (preferred) CT—head LP—CSF analysis (rare)
question

Give the Differential diagnosis for the following presentation: 21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees fl ashes of light in her right visual fi eld and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.
answer

Migraine (complicated) Tension headache Cluster headache Pseudotumor cerebri Trigeminal neuralgia CNS vasculitis Partial seizure Intracranial neoplasm
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Give the diffdx for the following presentation: 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months :
answer

Normal pressure hydrocephalus Alzheimer’s disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 defi ciency Neurosyphilis Hypothyroidism
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Give the w/u for the following presentation: 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months :
answer

CT—head LP—opening pressure and CSF analysis Serum B12 VDRL/RPR TSH
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Give the workup for the following presentation: 21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Prior to its onset, she sees fl ashes of light in her right visual fi eld and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.
answer

CBC ESR CT—head MRI—brain LP
question

Give the diffdx for the following presentation: 55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.
answer

Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke’s encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 defi ciency Neurosyphilis
question

Give the Differential diagnosis for the following presentation: 26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minute:
answer

Cluster headache Migraine Tension headache Sinusitis Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm
question

Give the workup for the following presentation: 26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minute:
answer

CBC ESR CT—head MRI—brain LP
question

Give the Differential diagnosis for the following presentation: 65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing:
answer

Temporal arteritis (giant cell arteritis) Migraine Cluster headache Tension headache Meningitis Carotid artery dissection Pseudotumor cerebri Trigeminal neuralgia Intracranial neoplasm
question

Give the w/u for the following presentation: 55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.
answer

CBC, electrolytes, calcium Serum B12 VDRL/RPR MRI—brain (preferred) CT—head EEG LP—CSF analysis Brain biopsy
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Give the diffdx for the following presentation: 70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness:
answer

Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina
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Give the w/u for the following presentation: 70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness:
answer

Glucose CBC, electrolytes Echocardiography ECG MRI—brain Doppler U/S—carotid
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Give the workup for the following presentation: 65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing:
answer

CBC ESR CRP Temporal artery biopsy Doppler U/S—carotid MRI—brain
question

Give the diffdx for the following presentation: 55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.
answer

Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm
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Give the w/u for the following presentation: 55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.
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Electrolytes CT—head MRI—brain LP
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Give the DiffDx for the following presentation: 57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.
answer

Trigeminal neuralgia Tension headache Migraine Cluster headache TMJ dysfunction Intracranial neoplasm
question

Key history for depressed mood:
answer

Onset, duration; sleep patterns; appetite and weight change; drug and alcohol use; life stresses, excessive guilt, suicidality, social function, decreased interest (anhedonia), decreased energy, decreased concentration, psychomotor agitation or retardation; family history of mood disorders; prior episodes; medications
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Key physical exam for depressed mood:
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Vital signs; head and neck exam; neurologic exam; mental status exam, including documentation of appearance,behavior, speech, mood, affect, thought process, thought content, cognition (measured by the 30-point mini-mental status exam), insight, and judgment.
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Give the diffdx for the following presentation: 68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
answer

Normal bereavement Adjustment disorder with depressed mood Major depressive disorder with psychotic features Schizoaffective disorder Depressive disorder not otherwise specifi ed (NOS)
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Give the w/u for the following presentation: 68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
answer

Physical exam Mental status exam TSH CBC Urine toxicology
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Give the diffdx for the following presentation: 42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.
answer

Major depressive disorder Substance-induced mood disorder Dysthymic disorder
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Give the w/u for the following presentation: 42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.
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Physical exam Mental status exam Blood alcohol level TSH CBC Urine toxicology
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Give the diffdx for the following presentation: 26 yo F presents with a 3-kg weight loss over the past two months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
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Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder
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Give the w/u for the following presentation: 26 yo F presents with a 3-kg weight loss over the past two months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
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Physical exam Mental status exam Urine toxicology
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Key history for Psychosis:
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Positive symptoms (delusions, hallucinations, disorganized thoughts, disorganized or catatonic behavior), negative symptoms (blunted affect, social withdrawal, decreased motivation, decreased speech/thought), cognitive symptoms (disorganized speech or thought patterns, paranoia); age of fi rst symptoms and/or hospitalization; previous psychiatric medications; alcohol and substance use.
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Key Physical Exam for psychosis:
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Vital signs; mental status exam.
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Give the diffdx for the following presentation: 19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to “guard against the evil empire.” ##### Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic Features
answer

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Give the W/u for the following presentation: 57 yo M c/o daily pain in the right cheek over the past month. The pain is electric and stabbing in character and occurs while he is shaving. Each episode lasts 2-4 minutes.
answer

CBC ESR MRI—brain
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Give the w/u for the following presentation: 19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to “guard against the evil empire.”
answer

Mental status exam Urine toxicology TSH CBC Electrolytes
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Key Historical questions for confusion/memory loss
answer

Must include history from family members/caregivers. Detailed time course of cognitive defi cits (acute vs. chronic/gradual onset), associated symptoms (constitutional, incontinence, ataxia, hypothyroid symptoms, depression); screen for delirium (waxing/waning level of alertness); falls, medications (and recent medication changes); history of stroke or other atherosclerotic vascular disease, syphilis, HIV risk factors, alcohol use, or vitamin B12 defi ciency; family history of Alzheimer’s disease
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Give the diffdx for the following presentation: 28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance
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Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition
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Key Physical exam man for confusion/ memory loss:
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Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities
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Give the w/u for the following presentation: 28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance
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Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr, AST/ ALT
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Give Diffdx for the presentation: 81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).
answer

Vascular (“multi-infarct”) dementia Alzheimer’s disease Normal pressure hydrocephalus Chronic subdural hematoma Intracranial tumor Depression B12 defi ciency Neurosyphilis Hypothyroidism
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Give the diffdx for the following presentation: 48 yo F presents with a one-week history of auditory hallucinations, stating, “I am worthless” and “I should kill myself.” She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
answer

Schizoaffective disorder Mood disorder with psychotic features Schizophrenia Schizophreniform disorder Psychotic disorder due to a general medical condition
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Give the w/u for the presentation: 81 yo M presents with progressive confusion over the past several years together with forgetfulness and clumsiness. He has a history of hypertension, diabetes mellitus, and two strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function).
answer

CBC VDRL/RPR Serum B12 TSH MRI—brain CT—head LP—CSF analysis (rare)
question

Give the diffdx for the following presentation: 48 yo F presents with a one-week history of auditory hallucinations, stating, “I am worthless” and “I should kill myself.” She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
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Mental status exam Beck Depression Inventory TSH CBC Electrolytes
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Give the diffdx for the presentation: 84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with diffi culty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
answer

Alzheimer’s disease Vascular dementia Depression Hypothyroidism Chronic subdural hematoma Normal pressure hydrocephalus Intracranial neoplasm B12 defi ciency Neurosyphilis
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Key history: Dizziness
answer

Lightheadedness vs. vertigo, ± auditory symptoms (hearing loss, tinnitus), duration of episodes, context (occurs with positioning, following head trauma), other associated symptoms (visual disturbance, URI, nausea); neck pain or injury; medications; history of atherosclerotic vascular disease.
question

Give the w/u for the presentation: 84 yo F brought by her son c/o forgetfulness (e.g., forgets phone numbers, loses her way back home) along with diffi culty performing some of her daily activities (e.g., bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
answer

CBC VDRL/RPR Serum B12 TSH MRI—brain (preferred) CT—head LP—CSF analysis (rare)
question

Key physical exam: Dizziness
answer

Vital signs; complete neurologic exam, including Romberg test, nystagmus, tilt test (e.g., Dix-Hallpike maneuver), gait, hearing, and Weber and Rinne tests; head and neck exam; cardiovascular exam.
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Give the diffdx for the following presentation: 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months :
answer

Normal pressure hydrocephalus Alzheimer’s disease Vascular dementia Chronic subdural hematoma Intracranial neoplasm Depression B12 defi ciency Neurosyphilis Hypothyroidism
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Give the diffdx for the following presentation: 35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
answer

MĂ©nière’s disease Vestibular neuronitis Labyrinthitis Benign positional vertigo Acoustic neuroma
question

Give the w/u for the following presentation: 72 yo M presents with memory loss, gait disturbance, and urinary incontinence for the past six months :
answer

CT—head LP—opening pressure and CSF analysis Serum B12 VDRL/RPR TSH
question

Give the w/u for the following presentation: 35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
answer

CBC VDRL/RPR (syphilis is a cause of MĂ©nière’s disease) MRI—brain
question

Give the diffdx for the following presentation: 55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.
answer

Creutzfeldt-Jakob disease Vascular dementia Lewy body dementia Wernicke’s encephalopathy Normal pressure hydrocephalus Chronic subdural hematoma Intracranial neoplasm Depression Delirium B12 defi ciency Neurosyphilis
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Give the diffdx for the following presentation: 55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension:
answer

Orthostatic hypotension due to dehydration (diarrhea, diuretic use) Vestibular neuronitis Labyrinthitis Benign positional vertigo Vertebrobasilar insuffi ciency
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Give the w/u for the following presentation: 55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension:
answer

Orthostatic vital signs CBC Electrolytes Stool exam (occult blood, fecal leukocytes)
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Give the diffdx for the following presentation: 65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
answer

Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure
question

Give the w/u for the following presentation: 65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
answer

Orthostatic vital signs CBC Electrolytes BUN/Cr MRI—brain
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Give the diffdx for the following presentation: 44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea
answer

Benign positional vertigo Vestibular neuronitis Labyrinthitis MĂ©nière’s disease
question

Give the w/u for the following presentation: 55 yo M presents with a rapidly progressive change in mental status, inability to concentrate, and memory impairment for the past two months. His symptoms are associated with myoclonus and ataxia.
answer

CBC, electrolytes, calcium Serum B12 VDRL/RPR MRI—brain (preferred) CT—head EEG LP—CSF analysis Brain biopsy
question

Give the diffdx for the following presentation: 70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness:
answer

Hypoglycemia Transient ischemic attack Arrhythmia Delirium Angina
question

Give the w/u for the following presentation: 44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea
answer

MRI—brain Audiogram
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Give the w/u for the following presentation: 70 yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, and weakness:
answer

Glucose CBC, electrolytes Echocardiography ECG MRI—brain Doppler U/S—carotid
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Give the diffdx for the following presentation: 55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.
answer

Vestibular neuronitis Labyrinthitis MĂ©nière’s disease Benign positional vertigo Vertigo associated with cervical spine disease/injury Vertebrobasilar insuffi ciency
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Give the w/u for the following presentation: 55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.
answer

CBC Electrolytes Electronystagmography MRI/MRA—brain
question

Give the diffdx for the following presentation: 55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.
answer

Subdural hematoma SIADH (causing hyponatremia) Creutzfeldt-Jakob disease Intracranial neoplasm
question

Give the diffdx for the following presentation: 55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI two days ago.
answer

Labyrinthitis Vestibular neuronitis MĂ©nière’s disease Acoustic neuroma Vertebrobasilar insuffi ciency
question

Give the w/u for the following presentation: 55 yo F presents with gradual altered mental status and headache. Two weeks ago she slipped, hit her head on the ground, and lost consciousness for two minutes.
answer

Electrolytes CT—head MRI—brain LP
question

Key history for depressed mood:
answer

Onset, duration; sleep patterns; appetite and weight change; drug and alcohol use; life stresses, excessive guilt, suicidality, social function, decreased interest (anhedonia), decreased energy, decreased concentration, psychomotor agitation or retardation; family history of mood disorders; prior episodes; medications
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Give the w/u for the following presentation: 55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI two days ago.
answer

Audiogram Electronystagmography MRI/MRA—brain
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Key History for Loss of consciousness:
answer

Presence or absence of preceding symptoms (nausea, diaphoresis, palpitation, pallor, lightheadedness), context (exertional, postural, traumatic; stressful, painful, or claustrophobic experience; dehydration); associated tongue biting, incontinence, tonic-clonic movements, prolonged confusion; dyspnea or pulmonary embolism risk factors; history of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use.
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Key physical exam for depressed mood:
answer

Vital signs; head and neck exam; neurologic exam; mental status exam, including documentation of appearance, 30-point mini-mental status exam), insight, and judgment.
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Key Physical Exam: Loss of consciousness:
answer

Vital signs, including orthostatics; complete neurologic exam; carotid and cardiac exam; lung exam; exam of the lower extremities.
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Give the diffdx for the following presentation: 68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
answer

Normal bereavement Adjustment disorder with depressed mood Major depressive disorder with psychotic features Schizoaffective disorder Depressive disorder not otherwise specifi ed (NOS)
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Give the diffdx: 26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues). ##### Seizure, grand mal (now called complex tonic-clonic seizure) Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia
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Give the w/u for the following presentation: 68 yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, and a 7-kg weight loss, all following his wife’s death. He cannot enjoy time with his grandchildren and reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
answer

Physical exam Mental status exam TSH CBC Urine toxicology
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Give the diffdx for the following presentation: 42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.
answer

Major depressive disorder Substance-induced mood disorder Dysthymic disorder
question

Give the w/u: 26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues). ##### CBC, electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG
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Give the w/u for the following presentation: 42 yo F presents with a four-week history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered fi ve similar episodes in the past, the fi rst in her 20s, and has made two previous suicide attempts. She further admits to increased alcohol use in the past month.
answer

Physical exam Mental status exam Blood alcohol level TSH CBC Urine toxicology
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Give the diffdx: 55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs ##### Drug-induced orthostatic hypotension (causing syncope) Cardiac arrhythmia Syncope (vasovagal, other causes) Stroke MI Pulmonary embolism
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Give the diffdx for the following presentation: 26 yo F presents with a 3-kg weight loss over the past two months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
answer

Bipolar I disorder Bipolar II disorder Cyclothymic disorder Major depressive disorder Schizoaffective disorder
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Give the w/u: 55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs ##### Orthostatic vital signs CBC Electrolytes CT—head ECG V/Q scan CT—chest with IV contrast
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Give the w/u for the following presentation: 26 yo F presents with a 3-kg weight loss over the past two months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
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Physical exam Mental status exam Urine toxicology
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Give the diffdx: 65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG). ##### Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism
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Key history for Psychosis:
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Positive symptoms (delusions, hallucinations, disorganized thoughts, disorganized or catatonic behavior), negative symptoms (blunted affect, social withdrawal, decreased motivation, decreased speech/thought), cognitive symptoms (disorganized speech or thought patterns, paranoia); age of fi rst symptoms and/or hospitalization; previous psychiatric medications; alcohol and substance use.
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Key Physical Exam for psychosis: ##### Vital signs; mental status exam.
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Give the w/u: 65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG). ##### ECG Holter monitoring CBC, electrolytes Glucose Echocardiography CT—head
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Key History: for numbness/weakness: ##### Distribution (unilateral, bilateral, proximal, distal), duration, ± progressive, pain (especially headache, neck or back pain); constitutional symptoms, other neurologic symptoms; history of diabetes, alcoholism, atherosclerotic vascular disease
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Key Physical Exam: for numbness/weakness ##### Vital signs; neurologic and musculoskeletal exams; relevant vascular exam
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Give the diffdx for the following presentation: 19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to “guard against the evil empire.” ##### Schizophrenia Schizoid or schizotypal personality disorder Schizophreniform disorder Psychotic disorder due to a general medical condition Substance-induced psychosis Depression with psychotic Features
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Give the w/u for the following presentation: 19 yo M c/o receiving messages from his television set. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes because he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room and has recently been hearing a voice from his television set telling him to “guard against the evil empire.”
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Mental status exam Urine toxicology TSH CBC Electrolytes
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Give the diffdx: 68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking. ##### Transient ischemic attack (TIA) Hypoglycemia Seizure Stroke Facial nerve palsy
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Give the w/u: 68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking. ##### CBC Glucose Electrolytes ECG CT—head MRI—brain Doppler U/S—carotid Echocardiography EEG
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Give the diffdx for the following presentation: 28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance
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Substance-induced psychosis Brief psychotic disorder Schizophreniform disorder Schizophrenia Psychotic disorder due to a general medical condition
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Give the diffdx: 68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking. ##### Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma
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Give the w/u for the following presentation: 28 yo F c/o seeing bugs crawling on her bed over the past two days and reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance
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Urine toxicology Mental status exam TSH CBC Electrolytes, BUN/Cr, AST/ ALT
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Give the w/u: 68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking. ##### CBC, electrolytes PT/PTT CT—head MRI—brain (preferred) Doppler U/S—carotid Echocardiography
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Give the diffdx: 33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI ##### Guillain-Barré syndrome Multiple sclerosis Polymyositis Myasthenia gravis Peripheral neuropathy Tumor in the vertebral ca
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Give the diffdx for the following presentation: 48 yo F presents with a one-week history of auditory hallucinations, stating, “I am worthless” and “I should kill myself.” She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
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Schizoaffective disorder Mood disorder with psychotic features Schizophrenia Schizophreniform disorder Psychotic disorder due to a general medical condition
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Give the w/u: 33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI ##### CBC, electrolytes CPK LP—CSF analysis MRI—spine EMG/nerve conduction study Tensilon test Serum B12
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Give the diffdx: 30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling “electric shocks” down her spine upon fl exing her head. ##### Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis
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Give the diffdx for the following presentation: 48 yo F presents with a one-week history of auditory hallucinations, stating, “I am worthless” and “I should kill myself.” She also reports a two-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
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Mental status exam Beck Depression Inventory TSH CBC Electrolytes
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Give the w/u: 30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling “electric shocks” down her spine upon fl exing her head. ##### CBC, ESR VDRL/RPR MRI—brain LP—CSF analysis Retinal evoked potentials
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Give the diffdx: 55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet. ##### Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 defi ciency Hypocalcemia Hyperventilation Paraproteinemia/myeloma
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Key history: Dizziness
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Lightheadedness vs. vertigo, ± auditory symptoms (hearing loss, tinnitus), duration of episodes, context (occurs with positioning, following head trauma), other associated symptoms (visual disturbance, URI, nausea); neck pain or injury; medications; history of atherosclerotic vascular disease.
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Give the w/u: 55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet. ##### HbA1c ESR Calcium Serum B12 Serum and urine protein Electrophoresis
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Give the diffdx: 40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning ##### Myasthenia gravis Horner’s syndrome Multiple sclerosis Intracranial tumor compressing CN III, IV, or VI Amyotrophic lateral sclerosis
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Key physical exam: Dizziness
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Vital signs; complete neurologic exam, including Romberg test, nystagmus, tilt test (e.g., Dix-Hallpike maneuver), gait, hearing, and Weber and Rinne tests; head and neck exam; cardiovascular exam.
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Give the w/u: 40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning. ##### Tensilon test ACh receptor antibodies (in serum) CXR CT—chest MRI—brain EMG
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Give the diffdx: 25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours. ##### Todd’s paralysis TIA Stroke Complicated migraine Malingering
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Give the diffdx for the following presentation: 35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
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MĂ©nière’s disease Vestibular neuronitis Labyrinthitis Benign positional vertigo Acoustic neuroma
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Give the diffdx: 25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours. ##### CBC, electrolytes EEG MRI—brain Doppler U/S—carotid
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Give the w/u for the following presentation: 35 yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
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CBC VDRL/RPR (syphilis is a cause of MĂ©nière’s disease) MRI—brain
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Give the diffdx for the following presentation: 55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension:
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Orthostatic hypotension due to dehydration (diarrhea, diuretic use) Vestibular neuronitis Labyrinthitis Benign positional vertigo Vertebrobasilar insuffi ciency
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Give the w/u for the following presentation: 55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started two days ago. She takes furosemide for her hypertension:
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Orthostatic vital signs CBC Electrolytes Stool exam (occult blood, fecal leukocytes)
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Give the diffdx for the following presentation: 65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
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Drug-induced orthostatic hypotension Vestibular neuronitis Labyrinthitis Benign positional vertigo Brain stem or cerebellar tumor Acute renal failure
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Give the w/u for the following presentation: 65 yo M presents with postural dizziness and unsteadiness. He has hypertension and was started on hydrochlorothiazide two days ago.
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Orthostatic vital signs CBC Electrolytes BUN/Cr MRI—brain
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Give the diffdx for the following presentation: 44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea
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Benign positional vertigo Vestibular neuronitis Labyrinthitis MĂ©nière’s disease
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Give the w/u for the following presentation: 44 yo F c/o dizziness on moving her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus and nausea
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MRI—brain Audiogram
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Give the diffdx for the following presentation: 55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.
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Vestibular neuronitis Labyrinthitis MĂ©nière’s disease Benign positional vertigo Vertigo associated with cervical spine disease/injury Vertebrobasilar insuffi ciency
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Give the w/u for the following presentation: 55 yo F c/o dizziness that started this morning. She is nauseated and has vomited once in the past day. She had a URI two days ago and has experienced no hearing loss.
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CBC Electrolytes Electronystagmography MRI/MRA—brain
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Give the diffdx for the following presentation: 55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI two days ago.
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Labyrinthitis Vestibular neuronitis MĂ©nière’s disease Acoustic neuroma Vertebrobasilar insuffi ciency
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Give the w/u for the following presentation: 55 yo F c/o dizziness that started this morning and of “not hearing well.” She feels nauseated and has vomited once in the past day. She had a URI two days ago.
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Audiogram Electronystagmography MRI/MRA—brain
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Key History for Loss of consciousness:
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Presence or absence of preceding symptoms (nausea, diaphoresis, palpitation, pallor, lightheadedness), context (exertional, postural, traumatic; stressful, painful, or claustrophobic experience; dehydration); associated tongue biting, incontinence, tonic-clonic movements, prolonged confusion; dyspnea or pulmonary embolism risk factors; history of heart disease, arrhythmia, hypertension, or diabetes; alcohol and drug use.
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Key Physical Exam: Loss of consciousness:
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Vital signs, including orthostatics; complete neurologic exam; carotid and cardiac exam; lung exam; exam of the lower extremities.
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Give the diffdx: 26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues).
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Seizure, grand mal (now called complex tonic-clonic seizure) Convulsive syncope Substance abuse/overdose Malingering Hypoglycemia
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Give the w/u: 26 yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues).
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CBC, electrolytes, glucose Urine toxicology EEG MRI—brain CT—head LP—CSF analysis ECG
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Give the diffdx: 55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs
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Drug-induced orthostatic hypotension (causing syncope) Cardiac arrhythmia Syncope (vasovagal, other causes) Stroke MI Pulmonary embolism
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Give the w/u: 55 yo M c/o falling after feeling dizzy and unsteady. He experienced transient LOC. He has hypertension and is on numerous antihypertensive drugs
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Orthostatic vital signs CBC Electrolytes CT—head ECG V/Q scan CT—chest with IV contrast
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Give the diffdx: 65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG).
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Cardiac arrhythmia (causing syncope) Severe aortic stenosis Syncope (other causes) Seizure Pulmonary embolism
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Give the w/u: 65 yo M presents after falling and losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His past history includes coronary artery bypass grafting (CABG).
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ECG Holter monitoring CBC, electrolytes Glucose Echocardiography CT—head
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Key History: for numbness/weakness:
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Distribution (unilateral, bilateral, proximal, distal), duration, ± progressive, pain (especially headache, neck or back pain); constitutional symptoms, other neurologic symptoms; history of diabetes, alcoholism, atherosclerotic vascular disease
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Key Physical Exam: for numbness/weakness
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Vital signs; neurologic and musculoskeletal exams; relevant vascular exam
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Give the diffdx: 68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.
answer

Transient ischemic attack (TIA) Hypoglycemia Seizure Stroke Facial nerve palsy
question

Give the w/u: 68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, and right hand weakness. His symptoms had totally resolved by the time he got to the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.
answer

CBC Glucose Electrolytes ECG CT—head MRI—brain Doppler U/S—carotid Echocardiography EEG
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Give the diffdx: 68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
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Stroke TIA Seizure Intracranial neoplasm Subdural or epidural hematoma
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Give the w/u: 68 yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski’s sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
answer

CBC, electrolytes PT/PTT CT—head MRI—brain (preferred) Doppler U/S—carotid Echocardiography
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Give the diffdx: 33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI ##### Guillain-Barré syndrome Multiple sclerosis Polymyositis Myasthenia gravis Peripheral neuropathy Tumor in the vertebral ca
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Give the w/u: 33 yo F presents with ascending loss of strength in her lower legs over the past two weeks. She had a recent URI ##### CBC, electrolytes CPK LP—CSF analysis MRI—spine EMG/nerve conduction study Tensilon test Serum B12
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Give the diffdx: 30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling “electric shocks” down her spine upon fl exing her head. ##### Multiple sclerosis Stroke Conversion disorder Malingering CNS tumor Neurosyphilis Syringomyelia CNS vasculitis
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Give the w/u: 30 yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling “electric shocks” down her spine upon fl exing her head. ##### CBC, ESR VDRL/RPR MRI—brain LP—CSF analysis Retinal evoked potentials
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Give the diffdx: 55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet. ##### Diabetic peripheral neuropathy Alcoholic peripheral neuropathy B12 defi ciency Hypocalcemia Hyperventilation Paraproteinemia/myeloma
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Give the w/u: 55 yo M presents with tingling and numbness in the hands and feet (gloveand- stocking distribution) over the past two months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet. ##### HbA1c ESR Calcium Serum B12 Serum and urine protein Electrophoresis
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Give the diffdx: 40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning ##### Myasthenia gravis Horner’s syndrome Multiple sclerosis Intracranial tumor compressing CN III, IV, or VI Amyotrophic lateral sclerosis
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Give the w/u: 40 yo F presents with occasional double vision and droopy eyelids at night with normalization by morning. ##### Tensilon test ACh receptor antibodies (in serum) CXR CT—chest MRI—brain EMG
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Give the diffdx: 25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours. ##### Todd’s paralysis TIA Stroke Complicated migraine Malingering
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Give the diffdx: 25 yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours. ##### CBC, electrolytes EEG MRI—brain Doppler U/S—carotid
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